PLEASE PRINT LEGIBLY First Middle Last Mailing Address Number Street Apt# City State Zip Mobile CALIFORNIA CERTIFYING BOARD FOR MEDICAL ASSISTANTS A Private Non-Profit Corporation PO Box 462 Placerville CA 95667 (530) 622-1850 Email: info@ccbma.org Website: www.ccbma.org CALIFORNIA CERTIFIED MEDICAL ASSISTANT EXAMINATION APPLICATION FAXED OR EMAILED APPLICATIONS WILL NOT BE ACCEPTED LEGAL NAME (Must EXACTLY match your United States government issued ID): Name change requests after submission of the application are subject to a $50 fee. Telephone Date of Birth Email **Applicants must be 18 years of age and provide copies of a valid US government issued ID or Driver s License AND current CPR certification. ** Work INITIAL EXAMINATION Basic and Clinical Specialty $ 145 Basic and Administrative Specialty $ 145 Basic, Clinical & Administrative Specialties $ 185 AFTER INITIAL EXAMINATION Second Specialty Administrative $ 90 Second Specialty Clinical $ 90 Retake exam - Basic $ 105 Retake exam- Clinical $ 90 Retake exam Administrative $ 90 Last exam date Exams passed Must-Test-By date RECERTIFICATION BY EXAMINATION Basic and Clinical Specialty (CCMA-C) $ 145 Basic and Administrative Specialty (CCMA-A) $ 145 Basic, Clinical & Administrative Specialties (CCMA-AC OR CCMA) $ 185 Expired Credential Reactivation Fee $ 50 Certification Date Certificate Number Name on Certificate NOTE: CLINICAL CERTIFICATION will require proof of injection and/or venipuncture training as outlined in the California Medical Assistant regulations: A) Ten (10) clock hours in administering injections and performing skin tests including satisfactory performance of at least ten (10) each of intramuscular, subcutaneous, and intradermal injections and ten (10) skin tests and/or B) Ten (10) clock hours in venipuncture and skin puncture for the purpose of withdrawing blood including at least ten (10) venipunctures and ten (10) skin punctures. CCBMA offers year-round Computer Based Testing (CBT). Many locations are available. You can locate the site nearest you by visiting our exam vendor s website at www.pearsonvue.com/ccbma and looking under Locate a Test Center. All sites are open Monday through Friday, and many are open Saturdays. Upon approval of your application, you will be notified of scheduling instructions for the exam. You will be required to select a specific site when you register. YOU WILL KNOW YOUR PRELIMINARY RESULTS BEFORE YOU LEAVE THE TEST SITE. Once certified, your certificate, wallet card and pin will be mailed to you along with recertification information. 1
ELIGIBILITY REQUIREMENTS An applicant for the California Certified Medical Assistant exam must satisfy at least one of the following requirements AND must provide copies of a valid US government issued ID or Driver s License AND current CPR certification. Graduate of an accredited medical assisting program* in the United States within one year preceding this application: Name of School: Address: Phone: (You must provide a copy of your Certificate of Completion from an accredited medical assisting course with this application). *Training in a secondary; post-secondary or adult education program in a public school authorized by the Department of Education; in a community college program; post-secondary institution approved by the Bureau of Private Post-Secondary and Vocational Education or Department of Consumer Affairs. Currently employed as a medical assistant by a licensed physician (MD/DO) or podiatrist (DPM) in the United States: Employer s Name: Phone: Address: Job Title: Attach verification of employment, such as a copy of your pay stub or physician-employer signed statement on office letterhead. At least two years employment comparable to full time (4160 hours) within the last five years as a medical assistant in the United States: Employer Name: Phone: Address: Job Title: Attach statement from previous employer/s verifying number of hours worked in the last five years AND a PHYSICIAN signed injection/venipuncture proficiency statement (page 3). Current employment as a Medical Assisting Instructor in an accredited institution in the United States: School Name: Phone: Address: Attach verification of employment, such as a copy of your pay stub or verification statement on employer letterhead. United States Military Training: Served in the capacity of a medical assistant while enlisted or either separated from the Military within the last year or served in that capacity for at least two of the previous five years. An injection/venipuncture proficiency statement (page 3) signed by your Commanding Officer is also required for applicants taking the Clinical exam. ***FAILURE TO INCLUDE NECESSARY DOCUMENTATION WITH INITIAL APPLICATION WILL DELAY THE APPLICATION PROCESS. *** 2
CERTIFICATE OF COMPETENCY FOR INJECTIONS AND/OR VENIPUNCTURE SCHOOL GRADUATE: Training to perform venipunctures and/or injections as required in Section 1366.1 of California Medical Assistant Regulations may be administered by a licensed physician or podiatrist, a registered nurse, licensed vocations nurse, or physician assistant. Training may also be administered by a qualified instructor in an accredited medical assisting program. The supervising physician, podiatrist, nurse or instructor shall certify in writing the place and date such training was administered, the successful completion of each task, and shall sign the certification. Medical assistants who are applying for CLINICAL certification are required to have: Ten (10) clock hours of training in administering injections and performing skin tests and/or Ten (10) clock hours of training in venipuncture and skin puncture for the purpose of withdrawing blood, and Training shall include instruction and demonstration in pertinent anatomy and physiology appropriate to the procedures, choice of equipment, proper technique (including sterile technique), hazards and complications, patient care following treatment or test, emergency procedures, and California law and regulations for medical assistants. Satisfactory performance by the trainee of at least ten (10) each of intramuscular, subcutaneous and intradermal injections, ten (10) skin tests and/or at least ten (10) venipunctures and ten (10) skin punctures.* I hereby certify that has received training in injections and/or venipuncture as defined in the California Medical Assistant Regulations. Location training was administered at:. Date training was completed:. This candidate has successfully performed the minimum number of required injections/venipunctures (stated in the paragraph above*) A training log documenting these procedures will be maintained at my facility. Print Instructor Name: Instructor Signature: Date: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ EMPLOYED: If you are currently employed or have been employed as a medical assistant, you must provide a proficiency statement signed by your physician-employer. STATEMENT OF PROFICIENCY I hereby certify that my current/previous (circle one) medical assistant is/was working within the Scope of Practice for a Medical Assistant and is proficient in administering injections and/or performing venipunctures. Physician (Print Name) Physician s Signature (MD, DO, DPM) Date Official office stamp Phone ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3
CANCELLATION AND POSTPONEMENT POLICY Failing to appear for a scheduled test, arriving more than 15 minutes after the scheduled start time, refused admission to the exam, or changed the exam date without providing 24 hours notice will result in forfeiture of the entire fee. There will be no refund. To reschedule the exam, do so by contacting Pearson Vue directly, our testing company, at the phone number found on the eligibility letter. You must test by the date that is specified in your eligibility letter. If you wish to cancel your exam, you must do so in writing to CCBMA, not less than 15 days prior to your scheduled exam or the must test by date and contact Pearson Vue directly to have your appointment removed from the system. If you meet these deadlines, you will receive a refund of the application fee paid minus a $50 processing charge. Cancellation requests must meet these criteria or no refund will be given. If your application is denied by CCBMA, you will receive a letter and a refund of your application fee minus a $50 processing charge. SPECIAL ACCOMMODATIONS Individuals requiring special provisions on examination day must request such exceptions in writing and it must be included with the initial application. Physical disability must be currently documented by a medical doctor. If you are requesting special accommodations because of a learning disability, documentation must be provided from a psychologist dated within the last year. The Certifying Board will make every effort to accommodate such cases, but it reserves the right to deny requests that, in the judgment of the Board, would jeopardize the security of the examination material or the integrity of scores derived from the examination. RELEASE OF INFORMATION I hereby give my permission for the Certifying Board to release my name, credential, email and mailing address to be used for educational and employment opportunities. No other information will be released without my knowledge and specific permission. YES, I give permission to release my information. NO, I do not want my information released. ACKNOWLEDGEMENT I acknowledge that I have read and understand the eligibility requirements, fees, cancellation/postponement, authorization of credit/debit card charges and refund policies, and that the information/documentation supplied in this application is true and accurate to the best of my knowledge. SIGNATURE DATE PRINT your name as you want it to appear on your certificate: (Please note that the name you registered under cannot be changed without documentation.) SUBMITTING YOUR APPLICATION: Please include all required supporting documentation and payment (Money order or credit card information). NO PERSONAL CHECKS ACCEPTED. Please contact me at ( ) for my credit card information OR my credit card information is attached on a separate sheet. Signature (if applicable for credit card charge) Signature above indicates permission to charge your credit card $ FAILURE TO INCLUDE NECESSARY DOCUMENTATION WITH THE INITIAL APPLICATION WILL CAUSE DELAYS IN PROCESSING THE APPLICATION. Rev. 1/2018 4
IF YOU ARE PAYING BY CREDIT CARD PLEASE COMPLETE THIS INFORMATION AND RETURN WITH YOUR APPLICATION My credit card is a (please circle) MasterCard Visa Discover American Express Examination Application Fee $145 or $185 or Other Expired Credential Reactivation Fee $50 Review Guide $25 (Out of Stock) Practice Test $15 Medical Math and Dosage Calculations Workbook $15 Please charge the card for $ Signature: (Required) Name as it appears on the card: Card Number: Expiration Date: 3 digit security code (on back of card): If cardholder is different from applicant, please indicate relationship: Billing address for cardholder: Shipping address (if different than billing address): Telephone number: 5